Do-Gooders and Go- Getters

Working paper Do-gooders and go- getters Career incentives, selection, and performance in public service delivery Nava Ashraf Oriana Bandiera Scott S. Lee March 2016 When citing this paper, please use the title and the following reference number: S-89236-ZMB-X DO-GOODERS AND GO-GETTERS: CAREER INCENTIVES, SELECTION, AND PERFORMANCE IN PUBLIC SERVICE DELIVERYú Nava Ashraf Oriana Bandiera Scott S. Lee March 18, 2016 Abstract We study how career incentives affect who selects into public health jobs and, through selection, their performance while in service. We collaborate with the Government of Zambia to design a field experiment embedded in the national recruitment campaign for a new health worker position. To identify the selection effect of incentives we experimentally vary the salience of career incentives at the recruitment stage, which triggers selection responses, but we offer the same incentives to all recruited agents, which mutes effort responses. Career incentives attract health workers who provide more inputs (29% more household visits, twice as many community meetings) and this is matched by an increase in institutional deliveries, breastfeeding, immunizations, deworming and a 5pp reduction in the share of underweight children. The results allay the concern that extrinsic rewards worsen public service delivery by crowding out pro-social agents. JEL classification: J24, 015, M54, D82. úAshraf: HBS and NBER, [email protected]. Bandiera: Department of Economics and STICERD, LSE, [email protected]; Lee: Harvard Medical School and Harvard Business School, [email protected]. We thank the Ministry of Health of Zambia and especially Mrs. Mutinta Musonda for partnership on this project. We thank the IGC, JPAL Governance Initiative, USAID and HBS DFRD for financial support. We also thank Philippe Aghion, Charles Angelucci, Roland Benabou, Tim Besley, Pedro Bordalo, Gharad Bryan, Robin Burgess, Robert Dur, Marcel Fafchamps, Greg Fischer, Matt Gentzkow, Paul Gertler, Maitreesh Ghatak, Bob Gibbons, Brian Hall, Kelsey Jack, Alan Krueger, Nicola Lacetera, Gerard Padro, Imran Rasul, Jonah Rockoff, Vandana Sharma, Jesse Shapiro, Bryce Millet Steinberg, Andrei Shleifer, Dmitry Taubinsky and Jean Tirole for comments, as well as seminar participants at several institutions. Adam Grant, Amy Wrzesniewski, and Patricia Satterstrom kindly provided guidance on psychometric scales. We thank Kristin Johnson, Conceptor Chilopa, Mardieh Dennis, Madeleen Husselman, Alister Kandyata, Allan Lalisan, Mashekwa Maboshe, Elena Moroz, Shotaro Nakamura, Sara Lowes, and Sandy Tsai, for the excellent research assistance and the Clinton Health Access Initiative in Zambia for their collaboration. 1 1 Introduction The effectiveness of public services crucially depends on the agents who deliver them.1 Govern- ments thus face the challenge of designing incentives that attract strong performers, a particularly important task given that performance differences between observationally similar agents are very large.2 Besides talent, which determines the marginal product of effort, performance in public service delivery depends on the agents’ social preferences, that is the extent to which they internalize the utility of the recipients of the services. A tension then arises if extrinsic rewards attract talented agents, whose effort is more productive, at the expense of pro-social agents who, other things equal, exert more effort. This is the extensive margin equivalent of motivation crowding- out, whereby extrinsic rewards can reduce performance by reducing the agent’s intrinsic motivation [Bénabou and Tirole (2003); Benabou and Tirole (2006)]. This tension also underpins a frequent argument made by policymakers that extrinsic rewards should be kept low so as to draw in agents who care sufficiently about delivering services per se. This paper tests whether extrinsic rewards, in the form of career incentives, attract agents who improve the delivery of community health services. We collaborate with the Government of Zambia to implement a nationwide field experiment in the context of a recruitment drive for a new position to deliver primary health care, the Community Health Assistant (CHA).3 Due to the shortage of medical staff, hiring the “right” CHAs can potentially make a great difference for the quality of health services and, ultimately, health outcomes in these communities. This setting is ideal for our purposes because the successful delivery of services requires medical talent as well as community trust and connection, that is, agents who internalize the needs of the service recipients (hence-forth, pro-social agents).4 In this settting, the extrinsic rewards available to the government to attract talent are career incentives. The question of interest is then whether career incentives improve service delivery by attracting talented agents or worsen it by displacing pro-social agents. The answer to this question requires addressing a key challenge in identifying the selection effect of incentives in general, namely that any incentive scheme that affects selection at the recruitment stage also affects motivation once agents are hired (see, for instance, Muralidharan and 1We use the term “public service delivery” to denote jobs that have a positive externality or pro-social component. Whether the government is the employer is neither necessary nor sufficient, as other types of organizations deliver public services, and the government also employs people for jobs that have no pro-social component, such as customs officers. To the extent that these offer opportunities for rent-seeking, they might attract agents who are more prone to corruption (Gorodnichenko and Peter, 2007; Hanna and Wang, 2013). 2This is a very well-established finding in the literature on teacher effectiveness (see, e.g., the review in Staiger and Rockoff, 2010 for extensive evidence from the U.S. and Araujo et al (2016) for a developing country context). The finding that observables do not predict performance has motivated recent attention to the effect of incentive design at the recruitment stage on teachers selection (Rothstein 2015) 3In the average community in our sample, the arrival of two CHAs represents a 133% increase in health staff. 4See, for example, Cherrington A, Ayala GX, Elder JP, Arredondo EM, Fouad M, Scarinci I. Recognizing the Diverse Roles of Community Health Workers in the Elimination of Health Disparities: From Paid Staffto Volun- teers. Ethnicity & disease. 2010;20(2):189-194. We discuss these positions and the policy debate in further detail in Section 2.1 2 Sundararaman (2011); Duflo et al. (2012); Miller et al. (2012)). Our identification strategy relies on the fact that, since the CHA position is new, potential applicants do not have information about the potential for career advancement. This allows us to experimentally vary the salience of career incentives at the recruitment stage, while providing the same actual incentives to all agents once hired. At that point, all agents move to the same training school where they are trained together for one year and given the same information about the job, including career benefits. Thus, all CHAs have the same information and face the same incentives once they start their jobs. The difference in performance between agents recruited with salient career incentives and those recruited without identifies the effect of career incentives on performance through selection. To implement this design we randomize the main job advertisements at the district level. We designed the job advertisements to make the contrast between extrinsic rewards and pro-social benefits as stark as possible. In treated districts, the advertisements make career possibilities salient by highlighting that CHAs are part of the Ministry of Health (MoH)’s hierarchy and that this gives them potential access to further training and promotion to higher-ranked positions such as nurse, clinical officer, and doctor. In control districts, the advertisements make salient benefits to the community, by highlighting that the main benefit of being a CHA is to serve the community. Our analysis follows the three steps in the causal chain that links service delivery to outcomes, allowing us to measure the full impact different types of CHAs have. First, we measure the effect of recruiting with career incentives on the inputs provided by the CHAs once hired—i.e., the quantity and quality of services they deliver. Second, we use administrative data to test whether recruiting CHAs with career incentives affects facility utilization in the areas where the CHAs operate. Third we survey households to measure the effect on health practices and health outcomes. Besides their inherent importance, the effect on facility utilization and health outcomes reflects both observable and unobservable inputs chosen by the CHAs, thus measuring the overall effect of career incentives. The first stage of the analysis follows the CHAs in the field over the course of 18 months to measure their performance in delivering health services. The CHAs’ main task is to visit households to conduct environmental inspections, counsel on women’s and children’s health, and refer them to the health post as needed (e.g., for routine checks for children and pregnant women, or for giving birth). Our core performance measure is the number of household visits completed over the study period. We find that CHAs recruited with career incentives conduct 29% more household visits and they do not neglect less visible dimensions– such as the duration of visits,

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